Distinguishing findings in the evaluation of suspected transfusion reactions

Reaction	Typical time course^*	Clinical findings	Laboratory findings	Implicated products
Acute hemolytic transfusion reaction	During transfusion or within 24 hours of transfusion completion	Fever, chills, hypotension, back pain, DIC	Hemoglobinemia, hemoglobinuria, positive direct antiglobulin (Coombs) test (may be negative if all cells have hemolyzed), findings of DIC (prolonged PT, prolonged aPTT, low fibrinogen, thrombocytopenia)	RBCs, plasma (much less common), rarely platelets Incompatible blood product (typically ABO incompatible due to clerical error)
Anaphylactic transfusion reaction	During transfusion or within 4 hours of transfusion completion	Hypotension, angioedema, wheezing, respiratory distress	Hypoxemia, IgA deficiency, anti-IgA	RBCs, platelets, plasma products
Transfusion-related acute lung injury (TRALI)	During transfusion or within 6 hours of transfusion completion	Respiratory distress, hypotension	Abnormal chest radiography, hypoxemia, transient leukopenia, anti-neutrophil or anti-HLA antibodies (if tested)	RBCs, platelets, plasma products
Transfusion-associated circulatory overload (TACO)	During transfusion or within 12 hours of transfusion completion	Respiratory distress, rales	Abnormal chest radiography, hypoxemia, increased BNP or NT-proBNP	RBCs, platelets, plasma products, and other fluids
Sepsis/bacterial infection	During transfusion or within 72 hours of transfusion completion	Fever, chills, hypotension, DIC	Bacteremia, leukocytosis, findings of DIC	Platelets most commonly implicated, but can be any product Product may show bacterial contamination
Febrile non-hemolytic transfusion reaction	During transfusion or within 4 hours of transfusion completion	Fever	None	All blood products, but plasma is much rarer
Allergic transfusion reaction	During transfusion or within 4 hours of transfusion completion	Hives, urticaria	None unless specific investigation is made	All blood products

The table includes some common findings but is not comprehensive and does not substitute for clinical judgment in the patient evaluation. Not all of the findings listed under each reaction will be present in every case. Refer to UpToDate topics on transfusion reactions for details of evaluation, diagnosis, and management.

aPTT: activated partial thromboplastin time; BNP: brain natriuretic peptide; DIC: disseminated intravascular coagulation; HLA: human leukocyte antigens; Ig: immunoglobulin; NT-proBNP: N-terminal BNP; PT: prothrombin time; RBCs: red blood cells.

* Except for sepsis/bacterial infection, all typical time course criteria are from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network Biovigilance Component. Septic transfusion reactions generally occur immediately after initiating the transfusion but may take time to develop depending on the size of the bacterial inoculum.

Adapted from: Sazama K, DeChristopher PJ, Dodd R, et al. Practice parameter for the recognition, management, and prevention of adverse consequences of blood transfusion. College of American Pathologists. Arch Pathol Lab Med 2000; 124:61.

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Distinguishing findings in the evaluation of suspected transfusion reactions